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Handout #10

LABOR AND DELIVERY

Theories of Labor

Uterine Stretch Theory

• Uterus becomes stretched and pressure
increases, causing physiologic changes that
initiate labor.
• According to this theory, “any hollow muscular
organ when stretched to capacity will contract
& empty…”

Fetal Adrenal Response Theory

• Hippocrates, the Father of Medicine, was 1 st
person to propose this theory w/c states that
certain hormones produced by the fetal adrenal
& pituitary gland initiates labor contractions.
Oxytocin Stimulation Theory
• Studies have shown that as pregnancy nears
term, oxytocin production by the posterior
pituitary gland increases while the production
of oxytocinase by the placenta decreases.
Progesterone deprivation Theory
• Progesterone helps maintains pregnancy by its
relaxant effect on the muscular muscles of the
uterus, thereby preventing uterine contractions.
Prostaglandin Theory
• It has been known that when the fetus has
reached maturity, the fetal membranes produce
large amounts of arachidonic acid w/c is Floating – is when the head is still
converted by maternal deciduas into movable above the pelvic inlet in
prostaglandin, a hormone that initiates uterine palpation.
contractions. Engagement – is the descent of the
Theory of the Aging Placenta biparietal plane of the fetal head to a
• As the placenta “ages”, it becomes less efficient, level low that of the pelvic inlet.
producing deceasing amount of progesterone. Fixation – is the descent of the fetal
• This progesterone decline allows the head to the inlet to a level that it can no
concentration of prostaglandin & estrogen to longer be moved.
rise steadily. 2. Increased Level of Activity
• Initiated by low progesterone level, the adrenal
Signs of Labor gland secretes large amounts of epinephrine or
1. Lightening “The Baby Dropped” adrenalin starting about 2 weeks prior to labor
• Lightening is the settling of the presenting part to provide the woman w/ energy for the
to the pelvic brim or inlet. strenuous work of delivering a baby.
• Lightening results in:  
– Relief of dypsnea 3. Slight Weight Loss
– Increased frequency of urination • About 2 weeks before labor, the woman
– Leg pains experiences sudden weight loss amounting to 1
– Increased vaginal discharge to 3 pounds.
– Decreased fundal height • This is due to the decline in progesterone level.

4. Increased Braxton-Hicks Contractions

• The irregular painless contractions of pregnancy
become stronger, longer, & more frequent
when labor is near at hand.
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5. Ripening of the Cervix

• Throughout pregnancy, the cervix feels softer Components of Labor/Factors Affecting Labor “6 Ps”
than normal to palpation similar to consistency
of an earlobe (Goodell’s Sign) 1. Passages
• At term, the cervix becomes softer described as • Hard passages: Bony prominence
“buttersoft”. • Soft passages: Lower uterine segment, cervix,
• This is an internal announcement that labor is vagina, pelvic floor & perineum
very close at hand. 2. Power
6. Uterine Contractions • Primary force: Involuntary uterine contractions
• Surest sign that labor has begun. • Secondary force: Voluntary use of thoracic,
7. Show diaphragm & abdominal muscles when the
• As the fetus descends in the birth canal, the mother “bears down”
continuous pressure exerted by the presenting 3. Passenger
part against the soft tissues result in the rupture • Fetal positions, presentation & attitude
of several blood vessels in the cervix. 4. Person
• Maternal attitude during labor
8. Rupture of Membranes 5. Position
• Rupture of membranes or bag of water is • Maternal position during labor & delivery
signified by a gush or steady trickle of clear fluid
from the vagina. 6. Psyche
• Refers to feelings that the woman brings to
True & False Labor labor
• For some, feelings may include apprehension &
fear; for others excitement are common

THE PASSAGES OF LABOR

Functions of the Pelvis
• It provides protection to the organs found w/in
the pelvic cavity
• It provides attachment to muscles, fascia &
ligaments
• It supports the uterus during pregnancy
• It serves as birth canal
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Types of Pelvis DIVISION OF THE PELVIS

1. Gynecoid
• The female type pelvis that is most ideal for
childbirth.
• The inlet of this type of pelvis is round shaped
with transverse diameter larger than
anteroposterior (AP) diameter.
2. Android
• The male-type pelvis that presents the most
difficulty during childbirth as the fetal head has
difficulty getting out of this pelvis.
• Its AP diameter is wider than its transverse
diameter.
3. Anthropoid
• The ape-like pelvis which is the deepest type of
pelvis. • The pelvis is divided into two parts,
• Its inlet is oval shaped with AP diameter wider 1. the false pelvis and
than transverse diameter. 2. the true pelvis.
•
4. Platypelloid TRUE PELVIS
• The flat pelvis which is the rarest type of pelvis a. inlet or pelvic brim is the entrance to true pelvis
found only in about 5% of women. • AP Diameters:
• Its transverse diameter is wider than its AP – Diagonal conjugate: 12.5 cm. it is the
diameter. distance between the midpoint of
sacral promontory and the lower
Parts of the Pelvis margin of symphisis pubis. Measured by
1. Inanimate Bones internal examination.
_ these bones form the anterior and lateral – Obstetric Conjugate: 11cm. it is the
aspects of the pelvis. It consists of the following parts: distance between the midpoint of
• Illium sacral promontory and the midline of
• Ischium symphisis pubis which is ascertained by
• Pubes subtracting 1 to 1.5 cm from the
2. Sacrum diagonal conjugate.
• the sacrum is a triangular shaped bone forming – True conjugate: 11.5 cm. distance
the posterior protion of the pelvis. between the midpoint of sacral
• It is composed of five sacral vertebra. promontory and the upper margin of
• The first sacral vertebrae, called sacral symphisis pubis.
promontory, is an important obstetrical • Transverse diameter: 13.5 cm
landmark used in measuring important pelvic • Right and left oblique diameter: 12.75 cm
diameters. b. Pelvic canal is situated between inlet and outlet
3. Coccyx • The pelvic canal curves at its lower half, below
• it is the posterior portion of the pelvis the level of the ischial spines.
composed of five fused vertebra. • AP diameter at level of Ischial spines: 11.5cm
• Its sacrococcygal joint joins the sacrum to • Posterior sagittal diameter: 7.5cm
coccyx and allows the coccyx some degree of
movement.
Contracted pelvis
• A contracted pelvis refers to a pelvis with a
measurement of less than 1.5 to 2cm in any of
its important diameters, and therefore, makes
vaginal delivery of the fetus not possible. A
contracted pelvis is suspected if:
• Lightening has not yet taken place after 37
weeks in primis.
• There is history of stillbirth, difficult labor and
forceps delivery in multis.
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Pelvic articulations
• Pelvic articulations or joints serve as points of
attachment between pelvic bones; they also
allow the bones some degree of movement.
• Symphisis pubis joins the two pubis bones
• Sacroiliac joints joins sacrum and iliac
• Sacrococcygeal joint joins sacrum and coccyx

Effect of hormones
• Hormones of pregnancy especially The Passengers of Labor
progesterone, causes relaxation and softening SUTURE LINES
of pelvic joints that result in increased mobility • The suture lines are important because they
of the pelvic bones. Increased joint and bone allow the skull bones to overlap, called
mobility: Molding, during delivery in order to reduce the
size of the fetal head.
• Sutures also provide allowance for further brain
The Passengers of Labor development.
– Sagittal suture – is located between the
The head of the fetus is the most important part of its 2 parietal bones
body because of the following reasons: – Frontal suture – is located between the
1. largest part of the fetal body 2 frontal bones
2. Usually the presenting part – Coronal suture – is located between
3. Least compressible frontal & parietal bones
– Lamdoidal suture – is located between
parietal & occipital bones
Structure of the Fetal Skull
CRANIAL BONES FONTANELS
• The fetal skull is composed of the Fontanels are membrane covered spaces between the
following cranial bones: intersections of suture lines.
– 1 frontal 1. Anterior Fontanel or Bregma
– 2 parietal bones • is formed by the intersection of the sagittal,
– 2 temporal bones frontal & coronal sutures.
– 1 occipital bone • It is diamond shaped & closes between 12-18
– 1 sphenoid bone months of age
– 1 ethmoid bone 2. Posterior fontanel or Lambda
• The frontal, parietal & occipital bones are the • Is formed by the intersection of sagittal &
most important fetal skull bones because they lambdoidal sutures.
form the presenting part when the fetus is in • It is triangular in shape & closes by 2-3 months
cephalic presentation. of age.

The Passengers of Labor

8 Cranial Bones

DIAMETERS OF THE FETAL HEAD

The fetal head is wider in its anteroposterior (front to
back) diameter than in its transverse (side to side)
diameter.
1. Transverse Diameters
• Biparietal: Average measurement is 9.5cm.
• Bitemporal: average measurement is 8 cm.
• Bimastoid: average measurement is 7 cm.
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2. Anteroposterior Diameters •
• Suboccipitobregmantic
- this is the smallest AP diameter of the fetal The Passengers of Labor
head FETAL PRESENTATION & POSITION
- When the head is fully flexed, it is this ATTITUDE OR HABITUS
diameter of the head that is presented Areas to look at for flexion:
- It is measured from the inferior aspect of • Head-discussed in previous paragraph
occiput to the anterior fontanel. • Thighs-flexed on the abdomen
- Average size is 9.5 cm • Knees-flexed at the knee joints
2. Anteroposterior Diameters • Arches of the feet-rested on the anterior
surface of the legs
• Arms-crossed over the chest
• Attitude of general flexion occurs when all of
the above are flexed appropriately as described.
STATION
• Station is the relationship of the
presenting part of the fetus to an imaginary line
drawn at the level of ischial spines of the
mother.
• It is used to determine the degree of
advancement or descent of the presenting part
through the pelvis & is measured in
centimeters.

• Occipitofrontal
- Measures from the bridge of the nose to the The Passengers of Labor
occipital prominence FETAL PRESENTATION & POSITION
- Average size is 12.5. • Zero station (0) is when the presenting part is
• Occipitomental ASSYNCLITISM
- Measured from the chin to the posterior • Assynclitism occurs when the sagittal
fontanel suture does not lie exactly midway between the
- Average size is 13.5 sacral promontory & the symphisis pubis but is
deflected posteriorly or anteriorly.
• When it is deflected posteriorly toward the
The Passengers of Labor sacral promontory, it is called Anterior
FETAL PRESENTATION & POSITION Assynclitism or Naegele’s Obliquity.
• When is deflected anteriorly toward the
symphisis pubis it is called Posterior
Assynclitism or Litzman’s Obliquity.
FETAL LIE
• Lie refers to the relationship of the long
axis of the fetus to the long axis of the mother.
• It describes the position of the spinal column of
the fetus in relation to the spinal column of the
mother.
FETAL LIE
1. Longitudinal Lie
2. Transverse Lie
3. Oblique Lie
•

The Passengers of Labor

ATTITUDE OR HABITUS
FETAL PRESENTATION & POSITION
• Attitude refers to the degree of flexion of the
FETAL LIE
fetal body, head & extremities, or the
PRESENTATION AND PRESENTING PART
relationship of fetal parts to each other.
• The presenting part is that part of fetal body
• The fetus usually assumes an attitude of
that enters the true pelvis 1st & w/c is also the
complete flexion.
1st part to come out during delivery.
- The spinal column is bent; head is flexed
• The presentation of the fetus is determined by
forward w/ the chin touching the chest, legs bent at the
fetal lie & attitude.
knees & the calves pressing against the thighs
•
- This is the ideal attitude of the fetus
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The Passengers of Labor • Vaginal delivery is not possible in shoulder

Types of Fetal Presentation presentation.
1. Cephalic Presentation: when it is the head that • Causes of shoulder presentation:
comes out 1st. a.) relaxed abdominal wall due to grand
a.) Vertex Presentation multiparity
• Occurs when the head is completely flexed so b.) pelvic contraction
that the chin touches the chest. c.) Placenta previa
b.) Sinciput Presentation
• Occurs when the head is partially flexed & the •
anterior fontanel is the presenting part.
• The occipitofrontal diameter (12.5 cm) is The Passengers of Labor
presented for delivery. Types of Fetal Presentation
c.) Brow Presentation 3.
• When the head is extended or bent backward
causing the occipitomental diameter (13.5 cm) •
to be presented for delivery.
d.) Face Presentation The Passengers of Labor
• Occur when the head is sharply extended Types of Fetal Presentation
causing the occiput to come in contact w/ the
back of the fetus. •
• During the course of labor, resistance in the
pelvic floor can cause the head to extend The Passengers of Labor
further causing neck fracture & damage to the Types of Fetal Position
cervical cord. POSITION
e.) Chin/Mentum Presentation • Position refers to the relationship of the
• Occur when the head is hyperextended w/ the presenting part to one of the quadrants of the
chin as the presenting part. mother’s pelvis.
• Pelvic Landmarks: the pelvis is divided into several
areas in order to locate accurately the position of the
The Passengers of Labor presenting part.
Types of Fetal Presentation - These areas are known as the four quadrants
d.) Face Presentation of the maternal pelvis.
2. Breech: when the feet or buttocks come out 1 st Pelvic Landmarks:
during delivery. • Left anterior quadrant
a.) Complete Breech • Left posterior quadrant
• Occurs when the feet & legs are flexed on the • Right anterior quadrant
thighs & the thighs are flexed on the abdomen. • Right posterior
b.) Frank Breech • Left transverse
• Occurs when the hips are flexed & the legs are • Right transverse
extended, the anterior thighs are in contact w/ Fetal points of direction: this is an arbitrary point on
the abdomen & the buttocks are the presenting the presenting part used to orient it to the maternal
part. pelvis (usually occiput, mentum or sacrum.) fetal points
• This is the most common type of breech of direction depend on presentation.
presentation. •
c.) Footling Breech
• Occurs when one or both feet (single or double The Passengers of Labor
footling) are the presenting parts. Types of Fetal Position
• •

The Passengers of Labor The Passengers of Labor

Types of Fetal Presentation Types of Fetal Position
2. Cephalic or head presentation:
• • Occiput (O). This refers to the Y sutures on the
top of the head.
The Passengers of Labor • Brow or fronto (F). This refers to the diamond
Types of Fetal Presentation sutures or anterior fontanel of the head.
2. • Face or chin presentation (M). This refers to the
3. Shoulder Presentation mentum or chin.
• In this presentation, the fetus is lying Breech or butt presentation:
perpendicular to the long axis of the mother & • Sacrum or coccyx (S). This is point of reference.
the shoulder is the presenting part. Shoulder presentation:
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• Scapula (SC) or its upper tip, the acromion (A) • Descent involves the entrance of the greatest
would be used for the point of reference. biparietal diameter of the fetal head to the
Coding of positions: coding uses the first letter of the pelvic inlet.
pelvic landmarks and fetal points of direction to simplify • Full descent occurs when the head extrudes
explaining the various positions. from the cervix & touches the vaginal floor
• The first letter of the code tells which side of causing the mother to feel pushing sensations.
the pelvis the fetus reference point is on (R for Descent
right, L for left). • When the mother begins to feel the urge to
• The second letter tells the specific presenting push, measure FHT because cord compression
part of the fetus (occiput-O, fronto-F, can occur after full fetal descent.
mentum-M, breech-s, shoulder-SC or A). • In primiparas, descent usually occurs w/
• The last letter tells which half of the pelvis the lightening at about 2 weeks before labor onset.
reference point is in (anterior-A, posterior-P, • In multiparas, descent usually takes place w/
transverse or in the middle-T). engagement at the start of labor.
• •

The Passengers of Labor

Types of Fetal Position Mechanism (Cardinal Movements) of Fetus
Possible positions: with the exception of shoulder (DFIEREE)
presentation, each presenting part has the possibility of
six positions. •
Possible positions:
Shoulders
• LADA: left acromiodorsoanterior Mechanism (Cardinal Movements) of Fetus
• LADP: left acromiodorsoposterior (DFIEREE)
• RADA: right acromiodorsoanterior
• RADP: right acromiodorsoposterior Flexion
• • As the fetal head moves deeper into the pelvis,
it meets resistance from the cervix, pelvic floor
The Passengers of Labor or walls of the pelvis.
Types of Fetal Position • This resistance causes the head to flex so that
• The most favorable and common fetal position the chin is brought in close contact w/ the
is LOA (left occipitoposterior) which means chest.
that the fetus is in vertex presentation • Flexion of the fetal head makes the smallest
(occipito), facing the anterior left side of the diameter of the head, soboccipitobregmatic
mother’s pelvis (left anterior). diameter, to be presented to the pelvis for
• The head usually accommodates itself on the delivery.
left side of the mother because of the bladder Internal rotation
placement to the right side. • When the head reaches the level of the ischial
• spines, it rotates from transverse diameter to
AP diameter so that its largest diameter is
The Passengers of Labor presented to the largest diameter of the outlet.
Types of Fetal Position • This movement allows the head to pass thru the
• LOP and ROP positions makes labor longer and outlet.
harder for the mother, involving more back • If the fetus starts to descend in LOA or LOT,
pain, as the head must make a 180 degree turn rotation is only a short distance – 45 to 90
pressing against the bony sacrum in process. degrees
• Knowing positions will help the nurse-midwife • If the head is in a posterior position, it may
to identify where to look for FHT. mean a turn of 180 degrees
• This is the reason why abdominal palpation is • Some fetuses do not rotate at all to anterior
performed before taking FHT. position & is born occiput posterior
• In breech, the FHT will be upper R or L •
quadrant, above the umbilicus.
• In vertex, FHT will be lower R or L quad, below
the umbilicus. Mechanism (Cardinal Movements) of Fetus
• (DFIEREE)

Extension
Mechanism (Cardinal Movements) of Fetus • The combined forces of uterine contractions,
(DFIEREE) pushing effort of the mother & the resistance of
the pelvic floor cause the head to extend
Descent towards the vaginal opening.
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• As the head extends, the chin is lifted up & then contractions occur spontaneously in the same
it is born. way as the heart muscles beat.
• In this movement, the fetal spine is no longer Characteristic of uterine contractions:
flexed, but extends to accommodate the fetal b. Intermittent
body to the contour of the birth canal. – Characterized by alternating periods of
• contraction and relaxation. Periods of
rest are necessary on order to allow
blood flow and oxygenation of tissues.
Mechanism (Cardinal Movements) of Fetus c. Involves discomfort: this is called labor pains and
(DFIEREE) caused by:
• Compression of nerve ganglia in the cervix
Restitution • Stretching of the cervix during dilation
• After the head is out, it will turn to its original • Stretching of the peritoneum overlying the
position before it assumed internal rotation. uterus
• As a result, the head is once again in line w/ the • Hypoxia of the contracted myometrium
shoulder & the back w/c is still inside the birth • Stretching of ligaments
canal. • Uterotropin are agents that prepare the uterus
• The return of the head to its original position is and cervix for labor. They cause the uterus to
called restitution. become irritable, sensitive to uterotonins and
• This movement makes it easier for the shoulder the cervix to soften.
inside to make an internal rotation. • Uterotonin are agents that stimulate uterine
• contraction such as oxytocin, prostaglandin and
endothelin-1.
Phases of Uterine Contractions:
Mechanism (Cardinal Movements) of Fetus 1. Increment or Crescendo
(DFIEREE) • The time when contraction is starting and
intensity is building up. This is the longest
External rotation phase.
• When the head comes out, the shoulder w/c 2. Acme or Apex
enters the pelvis in transverse position turns to • The peak of contraction.
anteroposterior position for it to become in line 3. Decrement or Decrescendo
w/ the anteroposterior diameter of the outlet & • The time when muscles start to relax.
be able to pass through the pelvis. •
• As the shoulder moves inside, it brings along
corresponding rotation of the head outside in
the same direction; w/c is called external Components of Labor
rotation. Powers (strength of uterine contractions)
•
Intensity refers to the strength of uterine contractions.
Intensity is classified as:
Mechanism (Cardinal Movements) of Fetus 1. Mild contractions
(DFIEREE) 2. Moderate contractions
3. Strong contractions
Expulsion Frequency
• When the head is born, the shoulder & the rest • Refers to the rate at which contractions are
of the body follow without difficulty. occurring.
• • It is measured from the beginning of a
contraction to the beginning of the next
contraction.
Components of Labor Duration
Powers (strength of uterine contractions) • Refers to the length of contraction.
• It is measured from the beginning of
The Powers of Labor (primary & secondary) contraction to the end of the same contraction.
1. Primary power: uterine contractions Interval
• The most important forces during the first stage • Refers to the time that lapse between two
of labor are the uterine contractions that cause uterine contractions.
the cervix to dilate and efface. • It is measured from the end of a contraction to
Characteristic of uterine contractions: the beginning of the next contraction.
a. Involuntary •
• Uterine contractions are involuntary and
independent of extrauterine control. Uterine
Components of Labor
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Powers (strength of uterine contractions) • Past experiences

• Coping skills
Upper and Lower Uterine Segments • Cultural & social background
• Retraction refers to the permanent shortening • Presence of significant others & support system
of the muscle fibers that occurs w/ each Labor pain is caused by:
contraction. • Compression of nerve ganglia in the cervix
• Retraction causes the uterus to differentiate • Stretching of cervix during dilatation
into 2 parts: • Stretching of peritoneum overlying the uterus
I. Upper Segment • Hypoxia of contracted myometrium
– This is the active part of the uterus • Stretching of ligaments
found at fundal area w/ great force. •
II. Lower Segment
– The lower passive portion of the uterus
contains less muscle fiber & is therefore
not as contractible as the upper Components of Labor
portion. Person in Labor
III. Physiologic Retraction Ring
– This is the boundary between the upper
active segment & lower passive 1st Stage: is associated w/ dilatation of the cervix,
segment. hypoxia of uterine muscle cells & stretching of lower
2. Secondary Forces abdominal wall & over the lower lumbar & sacral areas.
• The force is combined efforts of the diaphragm, 2nd Stage: is associated w/ hypoxia of muscle cells,
abdominal & thoracic muscles. distention of vagina & perineum & pressure on adjacent
• These groups of muscles are effective only in structures. The pain is felt in the lower portion of the
pushing the fetus out when the cervix is fully uterus, around the upper margin of the legs & in the
dilated. perineal area.
• 3rd Stage: is associated w/ uterine contractions &
cervical dilatation during the birth of placenta.
Position - Maternal position during labor
Components of Labor 1. Standing or Walking
Psyche (emotional condition of the mother) 2. Squatting
3. Side lying
Psyche /Psychological Outlook 4. Kneeling over a chair
• Refers to the feelings that the woman brings to •
labor
• For some, feelings may include apprehension &
fear; for others, excitement & wonderment are
common Components of Labor
• A major component is the woman’s Position
psychological readiness for labor
Factors affecting psychological readiness:
a.) Presence of a support person Position
b.) The degree of preparation for childbirth 5. Birthing Balls
c.) Past experiences & coping measures Position
d.) Accomplishment of the tasks of pregnancy 6. Hands and knees (on all fours)
e.) Ideally, the outcome is to provide the woman with as •
much control over the situation as possible.
•

Components of Labor
Position
Components of Labor
Person in Labor
•

Person in Labor
• The attitude of the mother during labor greatly
affects labor process & outcome. Maternal Stages of Labor
attitudes & behaviors during labor depend on
several important factors. They are:
• Perception & meaning of childbirth First Stage of Labor: Cervical dilatation and
• Readiness & preparation for childbirth effacement
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• The period from the onset of true labor •

contractions until full cervical dilatation &
effacement is achieved.
• Two important events take place during the 1 st
stage: Stages of Labor
a.) Cervical Effacement or Obliteration or Taking Up
b.) Cervical Dilatation
a.) Cervical Effacement or Obliteration or Taking Up •
• It refers to the shortening of the cervical canal
from a length of about 1 to 2 cm until it is paper
thin.
• Maternal & Fetal Responses of Labor
Physiologic Effects of Labor on a Woman

Stages of Labor Cardiovascular System

• Decrease blood flow to the uterus because the
contracting uterine wall puts pressure on the
• uterine arteries.
• The increase of blood remains in the woman’s
circulation.
• Do not take BP during contraction, it will lead to
Stages of Labor wrong reading.
• Pushing during labor may increase cardiac
output by 40%-50% above prelabor level.
b.) Cervical Dilatation Blood Pressure
• Refers to the enlargement of widening of the • Rises an average of 15mmhg due to increased
cervical canal. cardiac output. Higher increases could be a sign
• Uterine contraction causes dilatation by pulling of pathology.
the cervix over the presenting part, called Hemapoietic System
FERGUSON REFLEX. • There is sharp increase in the WBC
• The BOW & the FETAL HEAD also act as a wedge (leukocytosis)
in dilating the cervix. • Possibly a result of stress & heavy exertion
• • Average woman has a WBC of 25,000-30,000
cells/mm3
• Normal WBC count is 5,000-10,000 cells/mm3
Respiratory System
Stages of Labor • Increase RR to supply additional oxygen in
response to increase cardiovascular parameters
• Total oxygen consumption increases by about
• 100% during 2nd stage of labor
• May result to hyperventilation (same w/
strenuous exercise)
• Use appropriate breathing patterns during labor
Stages of Labor to avoid hyperventilation
Temperature Regulation
• Increased muscular activity associated w/ labor
Second Stage: Expulsive Stage/Delivery of the baby can result in a slight elevation (1F) temperature
• This occurs from full cervical dilatation until the • Diaphoresis occurs w/ accompanying
birth of the baby. evaporation to cool & limit excessive warming
• The main event of this period is the birth of the Fluid Balance
baby. • Increase insensible water loss due to
Third Stage: Placental Stage/Expulsion of the placenta diaphoresis & increase in rate & depth of
• This is the period from delivery of the baby to respiration (w/c cause moisture to be lost w/
the expulsion of the placenta. each breath)
• The main event in this period is the delivery of • Combination of decreased oral intake (NPO) &
the placenta. increased fluid losses may make IVF
Fourth Phase: Immediate Postpartum replacement necessary if labor is prolonged
Period/Transition phase Urinary System
• The period from delivery of placenta until the • Kidneys begin to concentrate urine to preserve
condition of the woman has stabilized. both fluid & electrolytes brought by decreased
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fluid intake during labor & increased insensible • Increased ICP caused by uterine pressure on the
water loss. fetal head serves to keep circulation from falling
• Pressure of the fetal head as it descends in the below normal during the duration of a
birth canal reduces bladder tone (ability of the contraction
bladder to sense filling) Integumentary System
• Asked woman to void every 2 hours • Minimal petechiae or ecchymotic areas on the
Musculoskeletal System fetal presenting part
• Throughout pregnancy, relaxin, an ovarian- • There may also be edema of the presenting part
released hormone, has acted to soften the (caput succeedeneum)
cartilage between bones Musculoskeletal System
Gastrointestinal System • The force of uterine contractions tends to push
• Becomes fairly inactive during labor, probably fetus into position of FULL FLEXION, the most
due to the shunting of blood to more sustaining advantageous position for birth
organs & also due to pressure on stomach & Respiratory System
intestines from contracting uterus • The process of labor aid in the maturation of
Neurological & Sensory Responses surfactant production by alveoli of fetal lung.
• Neurologic responses are related to pain • The pressure applied to the chest from UC &
(increased PR & RR) passage thru birth canal helps to clear lung
• Pain during labor is registered at uterine & fluid.
cervical nerve plexuses (11th & 12th thoracic •
nerves)
• At moment of birth, pain is centered on the
perineum as it stretches to allow fetus to move
past, registered at S2 to S4 nerves Danger Signs of Labor
Fatigue Maternal Danger Signs
• Tired due to burden of carrying much extra
weight
• Sleep hunger during the last month due to Maternal tachycardia, hypertension and hypotension
backache in side-lying position & fetal kicks that • A systolic pressure greater than 140mmhg &
awakens the woman diastolic pressure greater than 90mmhg
Fear • Increase in SP of more than 30mmh & DP of
• Review process of labor as a reminder that more than 15mmhg
labor is not strange; labor is predictable but • Falling BP may be the 1st sign of intrauterine
variable; contractions last a certain length but hemmorrhage
always have pain-free rest periods in between Abnormal pulse
• Woman worry that her infant may die or born • Most pregnant woman have a PR of 70-80bpm
w/ abnormality • PR normally increases slightly during 2nd stage of
Cultural Differences labor
• Address these differences, & make arrangement • PR greater than 100bpm in normal labor is
to accommodate her beliefs or customs unusual, may be an indication of hemorrhage
– Providing warm food/fluids Inadequate or prolonged contractions
– Saving placenta • If becomes less frequent, less intense, or
– Arrange for interpreter if w/ shorter in duration, may indicate uterine
communication barrier exhaustion. If not corrected, perform CS.
• • UC lasting longer than 70 sec should be
reported, it may begin to compromise fetal
well-being by interfering w/ adequate uterine
artery filling
Maternal & Fetal Responses of Labor Pathologic Retraction Ring
Physiologic Effects of Labor to Fetus • An indention across a woman’s abdomen
• May be a sign of extreme uterine stress &
possible impending uterine rupture
Neurologic System Abnormal Lower Abdominal Contour
• decrease FHR as much as 5bpm during • full bladder:
contraction due to exerted pressure on the fetal – A round bulge may appear on lower
head during contraction anterior abdomen
• Do not take FHT during contraction to avoid – pressure of fetal head may injure the
false reading bladder
Cardiovascular System – Pressure of bladder may not allow fetal
• Reduced oxygen & nutrients during head descend
contractions because uterine arteries are Increasing Apprehension
constricted causing slight fetal hypoxia
 12

• may be a sign of oxygen deprivation or internal IE as it is disallowed by law & as precautionary

hemorrhage measure.
Fever, foul smelling vaginal discharge • Inquire about other concerns of the woman
• May be a sign of chorioamniotis regarding labor fears, questions,
Vaginal bleeding misconceptions, etc.
• May be placenta previa or abruptio placenta Vital Signs
• 1. Vital signs are taken on admission.
2. Latent Phase:
• Take BP, PR & RR every 1-2 hours (depending
on hospital policy). A rapid pulse may indicate
Danger Signs of Labor hemorrhage & dehydration. Report to physician
Fetal Danger Signs any deviation from normal.
• Take temperature every 4 hours. Assess every
hour after rupture of membranes because of
High or Low FHR the increased risk of infection. Above normal
• FHR more than 160bpm (tachycardia) or less temperature may be due to infection or
than 110bpm (bradycardia) is sign of possible dehydration.
fetal distress 2. Latent Phase:
Meconium Staining • Take BP between contractions not during
• Amniotic fluid is greenish in color contraction as it tends to rise during a
• May be a sign of fetal distress contraction. Take every hour w/ patient in left
Hyperactivity lateral position. After anesthesia is
• Ordinarily, fetus is quiet & barely moves during administered, take every 15-20 minutes.
labor. • Check BP when woman complains of headache.
• May be a sign of hypoxia If it is normal, the cause of headache is probably
• Frantic motion is common reaction to oxygen the stress of labor. Encourage relaxation
need technique.
Oxygen Saturation • BP may decrease if taken w/ woman in supine
• When oxygen saturation level is under 40%, position & after anesthesia is given. BP may
assessed by catheter inserted to the cheek increase during UC & PIH. If result is suspicious,
• Ph ≤7.2 by fetal blood obtain by scalp puncture wait 2 minutes & read again.
– Suggests that fetal well-being is 3. Active & Transition Phase:
compromised • Take every 30 minutes to one hour (depending
– Normal saturation: 40-70% on hospital policy)
Cord Prolapse 4. Second Stage
• • Take every 15 minutes to one hour
5. Vital signs are taken more frequently in the presence
of complications & when certain procedures are done
such as induction & after administration of anesthesia.
Maternal & Fetal Assessment during Labor Plans for Newborn Care
• Intent to breastfeed or bottle feed
• Rooming in preference
OBTAIN PERSONAL DATA • Circumcision preference in male infant
• Name, address, telephone number, age, date of • Choice of pediatrician
birth, religion ASSESS IMMINENCE & PROGRESS OF LABOR
ASSESS MATERNAL CONDITION 1. Uterine Contractions (UC)
• Health History • Assess the ability of the uterus to dilate the
– Time & content of the last meal cervix
– Past & present illnesses, allergies, • Determining the progress of labor
immunization history, current • Detect abnormalities of uterine contractions
medications • Evaluate any signs of fetal distress.
– Ask if smoking, using alcohol & drugs – 2. Methods of Monitoring UC:
amount & time of last ingestion a.) Manual
Obstetric History • Assessment by palpation using fingers place
• Past pregnancies: parity, gravity, outcome of over fundus. Anew nurse may have difficulty
previous pregnancies, labor & puerperium (the assessing intensity of UC, a practice guide is to
period of up to about 6 weeks after childbirth, compare it w/ consistency of the following parts
during w/c the uterus returns to its normal size of the face:
called involution) • Can be indented as far as the tip of the nose:
• Present pregnancy: LMP & EDC, any problem Mild UC
encountered w/ present pregnancy. If the • As firm as the chin: Moderate UC
patient has a bleeding incident, do not perform • As firm as the forehead: Strong UC
 13

b.) External Pressure Monitor 1. IE is performed in between contractions when the

• Uses a tocodynanometer, a transducer that uterus is relaxed.
converts pressure to electrical signals. A flat 2. IE performed during a contraction causes a lot of pain
disk w/ flush plunger is secured over the & may cause intact membrane to rupture.
abdomen w/ an elastic belt. 3. Less IE is done once membranes have ruptured.
• As the uterus contracts, the abdominal wall 4. IE is not done in the presence of vaginal bleeding &
rises & presses against transducer. This cord prolapsed.
movement is converted to an electrical signal & 5. IE is a sterile procedure, wash hands & wear sterile
is recorded on a paper. gloves.
b.) External Pressure Monitor 6. Place patient in dorsal recumbent position. Place
• The external pressure monitor may not be as pillow under the head.
accurate as palpation by a skilled nurse. During IE:
• For example, in a thin & small woman, a mild • Check for escaping fluid & cord prolapsed
contraction may be interpreted as a strong before inserting fingers.
contraction. And in an obese woman who has a • Insert middle & index finger toward the
lot of adipose tissue, a strong UC may be posterior vaginal wall.
interpreted as a mild or moderate contraction. • Assess cervical consistence, it is buttersoft
c.) Internal Pressure Monitor during labor.
• Uses a catheter w/ sterile water. The catheter • Assess effacement; length of cervix is about 1-2
tip is inserted inside the uterus, just above the cm (2.5 cm. other book)
presenting part. • Assess dilatation, remember that index finger is
Assess & report the following abnormal findings: 1 cm & middle finger is 1.5 cm.
a.) intensity: if uterus does not relax completely During IE:
in between UC • Assess membranes if they are intact, during a
b.) duration: more than 70 seconds contraction they tend to bulge.
c.) interval: less than 2 minutes • Locate ischial spines at 4 & 8 o’clock position to
d.) frequency: exceeds 3 times every 10 min assess station.
Techniques: • Confirm presentation if it is cephalic (fontanels)
a.) when timing contraction place warm hands w/palms or breech (anus)
facing down over the fundus where the strongest UC • Establish position: in cephalic presentation,
can be felt note where fontanelles are pointing.
b.) use finger pads to feel for the UC as they are the •
most sensitive area of the palms
c.) Time 3-4 contractions to have a good picture of
frequency
d.) check the contractions every 15 to 30 minutes Maternal & Fetal Assessment during Labor
during the 1st stage
Show
• 1. Show is slightly blood tinged mucus discharge Status of Amniotic Fluid
that becomes heavier & more blood stained as 1. Every pregnant woman is instructed to report
labor progresses. In normal labor only an immediately any leakage of fluid from the vagina. This is
increasing amount of blood stained mucus because once membranes are ruptured:
discharge is expected not actual bleeding. • There is danger of cord prolapsed if fetal head is
not engaged.
• 2. The presence of vaginal bleeding is an • There is danger of serious intrauterine infection
abnormal sign that must be reported if delivery does not occur in 24 hours.
immediately. Instruct patient not to discard • Labor & delivery will most probably occur
away perineal pad as used for inspection. within 24 hours.
Internal Examination (IE) •
The purpose of IE is to assess the following:
1. Status of amniotic fluid
2. Consistency of the cervix
3. Effacement Maternal & Fetal Assessment during Labor
4. Dilatation
5. Presentation
6. Station 2. If not determine if membranes are ruptured, perform
7. Obtain pelvic measurement to assess status of BOW:
• Nurses & midwives are legally allowed to a. Nitrazine paper test
perform IE. However, they cannot perform IE if • Insert a sterile cotton-tipped applicator into the
the patient is bleeding during labor or has a vagina to moisten it w/ the suspected amniotic
history of bleeding during pregnancy. fluid
GUIDELINES WHEN DOING IE:
 14

• Touch nitrazine paper w/ cotton-tipped Maternal & Fetal Assessment during Labor
applicator
• Negative: Nitrazine paper is yellow if BOW is
intact FETAL ASSESSMENT DURING LABOR
• Positive: It will turn blue if BOW is ruptured 1. Methods of assessing FHT:
• Excessive amount of bloody show & bleeding • Stethoscope
can give false positive result because blood, like • Fetoscope (De-Lee stethoscope, Left
amniotic fluid, has almost the same pH & gives stethoscope)
the same reaction in Nitrazine. • Doppler
c. Positive Fern Test or Cervical Mucus • Electronic fetal monitoring equipments
• Take sample of vaginal secretion from cervix, 2. Intermittent monitoring of FHT can be accomplished
swab in a slide & allow it to dry for 5-7 minutes. using a stethoscope, fetoscope, hand held Doppler
View specimen under the microscope. device & external fetal monitor. The intermittent
• If ferning pattern is noted, it indicates ruptured auscultation of FHT is advisable for normal pregnancies.
membranes. a. Advantages:
• Ferning pattern is caused by the estrogen found • Woman has more freedom to move about
in the amniotic fluid. because no electrodes are attached to her.
d. Nile blue sulfate staining of fetal squammous cells in • The nurse can provide more attention to the
suspected amniotic fluid. woman & her partner.
e. Identification of high values of glucose, fructose, b. Disadvantages:
prolactin, alpha-fetoprotein or diamine oxidase in • The nurse must spend time in monitoring.
suspected amniotic fluid. • There is a possibility of missing an abnormal
f. Injection of various dyes such as Evans Blue, FHT.
methylene blue & flourescan into the amniotic sac via 3. Electronic fetal monitors can be applied externally or
abdominal amniocentesis. internally & may be used intermittently or continuously.
3. Immediately after membranes have ruptured: • Continuous electronic fetal monitoring of the
a. After rupture of BOW, the 1st intervention is to assess fetus is not necessary during normal labor.
FHR for one full minute. If bradycardia is present, • However, if the mother or the fetus is classified
perform IE to assess for cord prolapsed & change high risk, a more precise & continuous
position of the woman to relieve pressure on the cord. monitoring is desirable for early detection of
b. Assess odor of amniotic fluid. Cloudy & foul smelling complication.
amniotic fluid indicates infection. • Candidates of continuous electronic fetal
c. Assess the amount & color of amniotic fluid. It should monitoring would include:
be clear & straw colored w/ specks of vernix caseosa. a.) women w/ multiple pregnancy & other obstetric
• Green tinged: Fetal distress in non breech complications
presentation b.) those receiving oxytocin infusions
• Yellow colored: Hemolytic disease, c.) women who passed meconium stained amniotic fluid
hyperbilirubinemia d.) other high risk conditions
• Gray colored or cloudy: infection 3.1. External Fetal Monitor has a transducer that is
• Pinkish or Red Stained: bleeding placed on the maternal abdomen. Before applying the
• Brownish/Tea-colored/Coffee-colored: Fetal transducer, Leopold’s maneuver is done to locate the
death FHT & fetal back. The transducer is applied on the area
d. Record time of rupture, characteristics of fluid & FHR. of the abdomen where the fetal back is located.
• Fundic Height & correlate w/ AOG: Take fundic a. advantages:
height after asking the patient to empty her • Noninvasive & does not pose risk of infection
bladder. A full bladder may cause higher fundic • Provides continuous tracing of FHT
height. • Enable the nurse to detect signs of fetal
• Abdominal palpation (Leopold’s maneuver): compromise early
Perform abdominal palpation to determine fetal b. Disadvantages:
presentation. • May not be able to detect short term variability
• four maneuver's employed to determine fetal • Fetal movement & maternal movement may
position: interfere w/ continuous monitoring so woman
1) determination of what is in the fundus; is instructed to limit changing positions.
2) evaluation of the fetal back and extremities; •
3) palpation of the presenting part above the
symphysis;
4) determination of the direction and degree of
flexion of the head. Maternal & Fetal Assessment during Labor
•

3.2. Internal Fetal Monitor is attached to the fetal scalp.

Membranes must be ruptured & the cervix be partially
 15

dilated (at least 2 cm), & the fetus descends to be able • Is the difference between successive heart
to attach the electrode on the fetus. beats or the moment to moment fluctuations of
a. advantages: FHT.
• Not affected by fetal movement b. Long-term variability
• It provides continuous & accurate recording • Is wider fluctuations, over minute/s, that causes
even if the woman moves & changes position the wavy appearance in the FHT tracing in the
• It provides accurate information regarding monitor.
variability • Absent: no fluctuations in FHT
b. disadvantages: • Minimal: 5 BPM or less
• The primary risk for the invasive monitoring is • Moderate/Normal: 5BPM to 25
infection: • Marked: greater than 25BPM below or above
• Chorioamnionitis & Osteomyelitis or fetal scalp the baseline
cellulitis 3. Early Deceleration
• Trained practitioner must insert the electrode. • Rate of FHT decreases at onset of uterine
• contraction but return to normal before the end
of contraction.
• This is a normal response of the fetus to head
compression caused by UC.
Maternal & Fetal Assessment during Labor 4. Acceleration
• When the fetus moves, it is expected that the
FHT will increase.
Frequency of Monitoring FHT • Accelerations by at least 15BPM for 15 seconds
1. Low Risk: are considered normal.
• Latent Phase – take FHT every hour ABNORMAL FHT PATTERN
• Active Phase – take FHT every 15-30 minutes 1. Tachycardia
• Second Stage – take FHT every 5-15 minutes. As a. Moderate: 161 to 180 BPM, Marked: above 180 BPM
the fetus descends deeper into the birth canal, b. Causes:
some variable deceleration may be noted • Fetal distress – initial fetal reaction to poor
during uterine contraction because of cord oxygenation supply is tachycardia followed by
compression. This is usually not ominous as bradycardia
long as the FHR returns to normal baseline after • Maternal infection & fever; Dehydration
the end of the contraction & pressure against • Hyperthyroidism
the cord is relieved. • Drugs: Atropine, Vistaril, Ritodrine &
2. At Risk: FHT is taken more frequently or continuously: Terbutaline, Epinephrine, Caffeine,
• Latent Phase - take FHT every 30 minutes Theophylline, Cocaine
• Active Phase – take FHT every 15 minutes ABNORMAL FHT PATTERN
• Second Stage – take every 5 minutes 1. Tachycardia
3. Take FHT immediately after the rupture of the BOW, c. Management:
whether artificially or spontaneously. • Reduce maternal fever
4. Before & after: • Increase fluids
• Drug administration & at the peak action time • monitor for chorioamnionitis (inflammation of
of the drug the embryonic membrane that totally
• Ambulation of laboring woman surrounds the embryo)
• Performing invasive procedure: IE, enema, 2. Bradycardia
amnioinfusion catheterization a. Moderate – 100-119 BPM, Marked – below 100 BPM
5. After any significant change in the uterine contraction b. Causes:
is noted. • fetal hypoxia as a result of analgesia &
NORMAL FHT PATTERN anesthesia
1. Baseline Rate • maternal hypotension
• Normal: 120-160 BPM • prolonged umbilical cord compression
• Rates of 110-120 are usually acceptable if all • vagal stimulation caused by compression of
other signs are reassuring or normal head during contraction
• The baseline rate should be measured between • fetal decompression from prolonged hypoxia
uterine contractions, initially for a full 10 c. Management:
minutes period • place mother on the left side
2. Baseline Variability refers to FHT fluctuations caused • assess for cord prolapsed
by the balancing acts of the sympathetic (increase FHT) • administer oxygen
& the parasympathetic branches (decrease FHT) of the 3. Late Deceleration: FHT decreases during uterine
autonomic nervous system. The presence of normal contraction & do not return to normal after the end of
variability is a reassuring sign that the fetus’s nervous the same contraction is a sign of uteroplacental
system is intact. There are 2 types of variability: insufficiency.
a. Short-term variability (STV) or Beat to Beat variability a. Causes:
 16

• uterine tetany (spasm & twitching of muscles) using a stethoscope to facilitate subsequent
from oxytocin administration FHT auscultation.
• maternal supine hypotension •
• hypertensive disorders
• DM
• Chronic disorders
b. Management: Maternal & Fetal Assessment during Labor
• Position on left side
• Discontinue oxytocin
• Give mask oxygen at 8-10 L/m •
• Increase IVF
• Notify physician
• Prepare for birth if no improvement
• Tocolytics may be ordered by the physician to
relax the uterus & allow more blood flow to the Uterine Phases of Parturition (childbirth)
placenta
4. Sinusoidal Pattern: Decreased or absence of
variability in FHT
a. Causes: Phase 0
• Fetal hypoxia • This extends from the time before implantation
• Fetal anemia until late in pregnancy when the uterus is
• Fetal sleep (normal sleep cycle is about 20 relaxed or quiescent & the cervix is firm & rigid.
minutes) • Initiation of parturition is the transition from
• Prematurity Phase 0 to Phase 1
• Medications taken by the mother: magnesium Phase 1
sulfate, narcotics, tocolytics • This is the time when the uterus & cervix
5. Variable Pattern/Deceleration undergo several changes in preparation for
• Deceleration occurring at unpredictable times labor.
during contractions. • This phase occurs late in pregnancy & is
• It has erratic & jagged pattern in the FHT characterized by the uterus becoming more
tracing, shaped like a V, U or W owing to irritable as shown by more frequent & intense
sudden drops & elevations of FHT. Braxton-Hicks contractions. The lower uterine
a. Causes: segment is formed & the cervix softens in
• Most often due to cord compression. Note here preparation for dilatation.
that the deceleration is often not continuous, • The onset of Labor is the transition from Phase
occurring only as long as the cord is compressed 1 to Phase 2
& FHT normalizes when the compression is Phase 2
relieved after uterine contraction. • This is the time of active labor when the
• Oligohydramnios contents of the uterus are expelled.
b. Management: • It is divided into 3 stages:
• Relieve pressure on the cord: change position to • a.) cervical stage
lateral or knee chest. The compression is • b.) expulsive stage
relieved when the variability disappears & FHT • c.) placental stage
tracing is normal. of the baby & ends w/ the 1st ovulation after delivery.
• Perform IE to check for cord prolapsed Phase 3
• Give oxygen by face mask if persists after • This is the time when the newly delivered
changing position mother recovers from the effects of pregnancy
• Stop oxytocin infusion & childbirth.
• Notify physician • It begins from the birth of the baby & ends w/
• Amnioinfusuion (infuse saline into the uterus) the 1st ovulation after delivery.
may be performed by the physician to relieve •
compression
•

CARE OF PARTURIENT IN THE FIRST STAGE

Maternal & Fetal Assessment during Labor

LOCATION OF FHT Carry Out Dependent Functions:

• Mark the location in the abdomen where the • Perform the admission orders of the physician
FHT was auscultated if it is being monitored & other admission procedures of the institution
 17

w/c often include but not limited to the i. turn woman on her side and shave anal area.
following: j. instruct woman not to touch the perineum after it has
• Administer IVF per institution policy. IVF is been shaved and cleansed to keep it clean.
usually as SOP on laboring patients admitted in Turn patient on her back and drape.
hospitals. Care of the Bladder
• Initiate labor progress notes: FHT, uterine 1. A woman in labor should be encouraged to void
contractions, vital signs frequently, at least every 2 hours to prevent bladder
• Notify patient’s attending doctor upon patient’s distention because a full bladder:
request Delay fetal descent
IV Fluids Increases discomfort of labor
The purposes of inserting the IVF upon admission are: Predispose to urinary tract infection
1. Prevention of dehydration/fluid & electrolyte Can be traumatized during labor
imbalance 2. a distended bladder can be palpated above the
2. Having a life-line for emergencies symphisis pubis as it bulges or protrudes. Percussion of
3. Usually required before administration of anesthesia a full bladder produces a reasonant sound while empty
& analgesia bladder produces dull sound.
4. For administration of oxytocin after delivery to Foods & Fluids
prevent uterine atony 1. Early in labor, clear fluids may be allowed. If not, the
Perineal Preparation woman may be given ice chips to prevent drying of the
1. Purpose mouth and for comfort.
• a. to clean & disinfect the external genitalia in • During active labor, foods and oral fluid should
order to prevent contamination & infection of be withheld because gastric emptying is
the birth canal. prolonged. Foods taken stays in the stomach
• There is no difference in infection site rate longer which the woman may vomit and
among women whose hair were clipped & not aspirate especially if she has been given
clipped. anesthetics and analgesics.
• Shaving increases infection because of the Ambulation
myriads of nicks that can occur 1. Encourage woman to ambulate during the latent
• b. To provide better visualization of the phase of labor to shorten first stage if membranes are
perineum still intact. When the woman stands or squats, the
2. Important Considerations diameter of the inlet is increased making the passage of
a. Assemble all equipments & materials to be used the fetus through the birth canal faster and easier.
b. Provide good lighting 2. Ambulation has also been found to decrease the
c. Ensure privacy & comfort during the procedure, need for analgesia, decrease incidence of FHT
drape properly. Use bed screen if patient is in ward abnormalities and to promote comfort
d. Explain the procedure to patient to allay anxiety & Enema
gain cooperation • 1. Enema is a procedure of emptying the colon
3. Procedure: Perineal Preparation of fecal matter to:
a. Wash hands & wear gloves • Stimulate uterine contractions
b. Place patient supine w/ legs flexed & dropped • Prevent infection- expulsion of feces during the
sideways, heels facing each other second stage predispose mother and infant
c. Place patient on bedpan infection
d. Using cotton balls (sterile sponges, disposable or • Facilitate descent of fetus
reusable wash cloths can also be used) soaked in mild 2. Enema is not a routine procedure in the preparation
antiseptic solution, cleanse perineum from front to of woman in labor. Commonly used enemas are tap
back. Moving from clean to dirty area. Anything that has water enema, fleet enema and prepacked disposable
passed over the anal area should not be returned to the type enema. Soap suds enema is not recommended
vulvar area to prevent infection. Do not let solution because they have been associated with several
enter the vaginal introitus. complications. Suppositories are also used.
e. pour warm water over the vulva to rinse it. 3. Contraindications to enema:
f. after cleaning the vulva, turn woman on her side and • Not given during active phase and ruptured
flex thighs and hips to expose perineal and anal area. BOW
Cleanse. • Vaginal bleeding
g. if perineal shaving is to be done, soap and lather the • Abnormal fetal presentation and position
hair of vulva to soften it, use dry gauze square to stretch • Fetus not yet engaged
the skin while shaving hair. The skin is stretched to keep • Premature labor because of the danger of cord
it taut so that the razor will move smoothly over it prolapsed
avoiding skin cuts. Start from labia majora moving • Abnormal fetal heart rate pattern
towards the direction of the anal area. Use single Transfer to Delivery Room
strokes. Rinse razor after each stroke. • 1. Primiparas are transferred to the delivery
h. when shaving is finished, wash with antiseptic soap room when the cervix is fully dilated and
and sterile water. Check for thoroughness. perineum is bulging.
 18

• 2. Multiparas are moved to DR when cervix is •  

8cm dilated 2.Dorsal Recumbent
• • Procedure:
– The head of the bed is 35 to 45 degrees
elevated, knees are flexed and feet flat
on bed. This position facilitates the
pushing effort of the mother.
CARE OF PARTURIENT IN THE SECOND STAGE • Indication: Home delivery
• Advantage: This position gives easy access to
the perineum providing the birth attendant with
good control of the delivery of the baby.
• The second stage of labor begins as soon as the • Disadvantages: Supine hypotensive syndrome
cervix is fully dilated and is completed with the and may be uncomfortable.
birth of the baby.  
• Never leave the patient alone once she is 3. Side-lying position
transferred to the delivery room. • Procedure: The woman is placed on her side
• Never turn your back on the perineum because • Indication: Heart disease
the baby could push through the vaginal • Advantage: This position increase comfort to
opening while your back is turned. the mother and avoids supine hypotension
• syndrome.
• Disadvantages:
– Less control of delivery and decreased
access to the perineum.
– Danger of woman losing balance during
CARE OF PARTURIENT IN THE SECOND STAGE delivery.
•

SIGNS OF THE SECOND STAGE OF LABOR

PREPARE DELIVERY EQUIPMENTS
• Place the instrument table near the delivery CARE OF PARTURIENT IN THE SECOND STAGE
table and uncover it.
• Prepare instruments to be needed by the
newborn. Turn on radiant warmer and place
receiving blanket under it to warm. STERILE PREP
• Ready resuscitation equipments. • Using a gloved hand, cleanse perineum, anus,
• Prepare also forms and charts that must be and upper inner thighs with an antiseptic
filled up in delivery room. solution. The direction should always be from
DELIVERY POSITION the vulva outwards, from clean to dirty area.
• Anesthesia, if indicated, is administered first Each sponge is discarded after use.
before the woman is made to assume the • The woman is catheterized (if ordered) after the
delivery position. perineal cleansing and draped properly. The
1. Lithotomy position - Procedure: vulva, perineum and anus are left exposed.
– Cover legs of woman with sterile cotton •
leggings and raise them up to the
stirrups at the same time.
– Adjust the stirrups so that the legs are
not widely separated and so that both
legs are of the same height. CARE OF PARTURIENT IN THE SECOND STAGE
– Elevate the head portion of the table to
enable the woman to push effectively.
• Indication: This position is used when surgical
procedures, such as forceps and episiotomy are PREVENTING INFECTION
to be performed. • Persons with infection or have been exposed to
• Advantage: This position gives east access to infections or communicable disease are not
the perineum providing the birth attendant with allowed to enter the DR.
good control of the delivery of the baby. • No one should be permitted in the DR without a
• Disadvantages: sub suit, mask covering mouth and nose and
– Supine hypotensive syndrome cap that completely covers hair. Anything that
– Positioning injuries: Clot formation due touches the patient’s perineum should be
to compression, muscle strain when sterile.
legs are improperly placed on stirrups.
 19

• Ideally, nurses and midwives attending delivery – To push 3 to 5 times with each
must wear eye shields, gowns and gloves to contraction but push no longer than 5
protect themselves from accidental splashing of to 6 seconds.
blood and body fluids. 2. To avoid exhaustion, instruct the woman to pant
• During labor, the nurse-midwife should perform (rapid shallow breathing) during some contraction. If
handwashing before and after patient care, woman complains of lightheadedness and tingling
when providing care between patients and sensations on fingers (this is respiratory alkalosis) let
whenever there is contact with blood and body her breathe through a paper bag or cupped hand.
fluids. 3. The woman may complain of leg cramps. This is due
• In addition, the nurse-midwife should also wear to the pressure exerted by the fetal head against the
gloves at all times that there is possibility of pelvic nerves. Provide relief by dorsiflexing the affected
touching body fluids and when performing any foot and straightening the leg until the cramps
procedure at or near the perineum. disappear.
• When handling perineal pads, they should be 4. As the presenting part moves towards the outlet,
handled from ends using gloved hands and not perform ironing on vaginal orifice to stretch and
in the middle area. prepare soft tissues.
ASSISTING MOTHER IN THE DELIVERY ROOM 5. When the head is crowning (largest diameter of the
1. Coach mother to push effectively, instruct her: head encircles the vulvar ring):
– To avoid the Valsalva maneuver, this – Instruct mother to pant and not to push
involves holding breath and tightening to prevent rapid expulsion of the baby
the abdominal muscles while pushing. and to avoid lacerations. Rapid
Valsalva maneuver decreases blood expulsion will result in sudden change
returning to the heart, increases venous of intracranial pressure which can cause
pressure and increases intathoracic cerebral hemorrhage in infant.
pressure which consequently, – Episiotomy if necessary is performed at
diminishes blood supply to placenta and this time by the doctor to prevent
fetus. lacerations.
There are two methods of pushing: •
• Urge to push method when the
woman pushes only when the
urge to push is felt and relaxes
completely after a contraction
to replenish her energy. CARE OF PARTURIENT IN THE SECOND STAGE
• Open-glottis pushing when the
woman pushes during uterine
contraction with open glottis so
air is released as she pushes. 6. Perform Ritgen’s maneuver while delivering the head.
• The woman may use any Place a sterile towel over the rectum and apply forward
method but she should never pressure on the chin while the other hand presses
be left alone when doing downward the occiput. Ritgen’s maneuver will:
pushing. – Facilitates extension of the head
• – Slows down deliver of the head
– Lets the smallest diameter of the head
to be born
•

CARE OF PARTURIENT IN THE SECOND STAGE

CARE OF PARTURIENT IN THE SECOND STAGE

•

7. Deliver the head slowly in between contractions.

Immediately after the delivery of the head:
CARE OF PARTURIENT IN THE SECOND STAGE – Wipe the nose and mouth of secretions,
suction with bulb syringe to establish
patent airway.
– Insert fingers into vagina and feel for
– To grasp below the knees or other hard cord looped around the neck (nucchal
objects as she bears down. cord). If present, slip cord down the
 20

shoulder or over the baby’s head. If – Use of oxygen and suction on the
tight, clamp twice and cut in between. infant.
8. Holding the sides of the head with two hands, apply a – Number of vessels in the cord.
slight downward push to deliver the anterior shoulder, – Any or other pertinent facts about the
and then elevate the head to deliver the posterior delivery.
shoulder. The rest of the body follows without difficulty –
after the delivery of the shoulder.
9. Take note of the exact time of baby’s birth. A child is
considered born when the whole body is delivered.
10. Immediately after birth of baby, place newborn in
dependent position to facilitate drainage of secretions. CARE OF PARTURIENT IN THE THIRD
9. Place the infant over the mother’s abdomen to help STAGE
contract the uterus.
• Clamping the cord:
– Usually, the cord is clamped after
pulsation has stopped to allow METHODS OF PLACENTAL SEPARATION
transfusion of about 50 mL of extra • Schultz Mechanism – Separation of the
blood from placenta to infant. This placenta starts from the center. The shiny
practice provides additional iron and smooth fetal side is delivered first in this type of
helps prevent iron deficiency anemia. separation. About 80% of placental separation
– Clamp the cord twice and cut in occurs by Shultz Mecahnism.
between, about 8 to 10 inches from the • Duncan Mechanism – Separation begins from
umbilicus. the edges of placenta. The maternal side is
• delivered first. About 20% of separation occurs
by Duncan Mechanism.
•

CARE OF PARTURIENT IN THE SECOND STAGE

CARE OF PARTURIENT IN THE THIRD STAGE

– After cutting the cord, count blood

vessels, there should be two arteries
and one vein. The vein is larger than the METHODS OF PLACENTAL SEPARATION
two arteries. MATERNAL ASSESMENT
– Later in the nursery, the cord is cut 1. Monitor vital signs every 15 minutes.
again and umbilical cord clamp – Tachycardia and failing BP may be due
(Hollister, Double Grip Umbilical Clamp) to hemorrhage and shock and should
is applied about 2 to 3 cm from the be reported immediately.
abdomen. – Suspect amniotic fluid embolism if
– Clamp the cod after baby’s delivery woman complains of sudden dyspnea,
without waiting for pulsation to stop in chest pain and tachypnea. Refer to
cases of twins, maternal physician at once.
alloimmunization and prematurity. 2. Monitor time interval between birth of the baby and
– Wrap the infant in sterile diaper, show the placenta.
to mother or let her hold the baby • Normally, the placenta is delivered within 5 to
(depending on institution’s policy). Be 20 minutes after baby’s birth.
sure to establish eye contact between • If a longer period of time elapsed before the
mother and baby to promote bonding placenta is delivered, the mother is at risk of
before bringing newborn to nursery. losing greater than normal amount of blood in
14. Wrap Record the delivery. Information to include in the third stage.
the nurses’ notes are: 3. Watchful waiting: If the uterus remains contracted
– Exact date and time of delivery. and there is no severe bleeding, watchful waiting is
– Sex of the infant. employed until the placenta is delivered.
– Condition of the infant (APGAR) after – Do not hurry placental delivery. No
birth. fundal push, no uterine massage and no
– Position of the infant at delivery. pulling of the cord. These actions can
– Type of episiotomy, lacerations. result in uterine inversion.
– Spontaneous or forceps delivery. – Rest one hand over the fundus to make
sure the uterus remains firm and does
not fill with blood.
 21

– Wait for signs of placental separation: hypotension. Its major adverse effect is
• Calkin’s sign is usually the first antidiuresis or fluid retention.
sign of placental separation. •
The uterus becomes firm and
globular rising to the level of
umbilicus.
• Sudden gush of blood from the
vagina. CARE OF PARTURIENT IN THE THIRD STAGE
• Lengthening of the cod as the
placenta separates from the
uterus.
• Appearance of the placenta at MAJOR SIDE EFFECTS
the vaginal opening. • Ergonovine maleate (Ergotrate) 0.2 mg: This is a
• Place a hand just above the symphisis pubis drug obtained from ergot, a fungus that grows
with palms facing the umbilicus, push the on rye and other grains.
uterus upwards. With the other hand, tract the • This drug is a powerful stimulus of uterine
cord slowly while gently rotating it around the contraction, with an effect that persists for
clamp until the placenta come out. Rotate the hours.
placenta as you deliver it. Inspect for • Thus it is very effective for the control of
completeness of cotyledons right after placental postpartum hemorrhage. However the adverse
delivery. Retained placental fragments can effect of this drug is hypertension so it is
cause severe hemorrhage by preventing the contraindicated in women with elevated blood
uterus to contract. pressure.
– Suspect a succenturiate lobe retained in Care when administering oxytocin:
the uterus when upon inspection of the • Never leave client unattended.
placenta after delivery fetal vessels are • Have oxygen and emergency equipment
coursing to the placental edge and available.
abruptly ending at a tear in the • Use infusion control device for IV
membranes. administration.
5. Massage the uterus to keep it contracted. • Discontinue if abnormal UC occur.
6. Placental expression: If bearing down effort of the • Assess BP and pulse every 15 minutes.
mother is not enough to deliver the placenta, apply • Monitor FHR.
gentle downward pressure on the fundus to expel the •
placenta. Make sure the uterus is firm or contracted
and placenta has already separated when performing
placental expression to prevent uterine inversion.
7. Oxytoxic agents are drugs that stimulate the uterus to
contact. It is given to: CARE OF PARTURIENT IN THE THIRD STAGE
– Initiate labor – Given slowly and in small
doses until desired UC are achieved.
– Used to augment weak UC that has
already begun. Record the following information in the notes:
– Used to control postpartum atony – – Time the placenta is delivered.
May be given rapidly as a bolus to – How delivered (spontaneously or
immediately control bleeding. manually removed by the physician).
• Route: IV, IM, oral and nasal – Type, amount time and route of
• administration of oxytocin. Oxytocin is
never administered prior to delivery of
the placenta because the strong uterine
contractions could harm the fetus.
– If the placenta is delivered complete
CARE OF PARTURIENT IN THE THIRD STAGE and intact or in fragments.
•

• Oxytocin (Pitocin, Syntocinon) 10 units: It is

ideally given IM in a dose of 10 USP units or as a
much more dilute solution by continuous CARE OF PARTURIENT IN THE FOURTH STAGE
intravenous infusion. Oxytocin should not be
given intravenously as a large bolus because it
causes titanic uterine contractions and
 22

• The main danger during the fourth stage is • 2. If the patient in stable, take them every
hemorrhage. Therefore the goal of nursing care 2-4 hours in the succeeding hours after transfer.
during this period is to prevent bleeding from If not, continue monitoring frequently.
uterine atony and birth canal lacerations • 3. The temperature may be slightly
sustained during labor. increased during the immediate postpartum
REPAIR OF LACERATIONS period because of mild dehydration.
• 1. Right after the birth of placenta, the ASSESMENT OF THE FUNDUS
perineum is inspected carefully for lacerations • 1. Check fundus for consistency every 15
and necessary repairs are made. During minutes during the first hour or until it no
episioraphy (repair of episiotomy and longer tends to relax. The first action to take
lacerations) a local anesthesia is injected to the when a baggy or relaxed uterus is noted is to
area to be repaired. massage the fundus gently to stimulate uterine
• When the uterus feels firm but there is contraction. If the fundus does not respond to
continuous oozing of bright red blood, suspect massage and bleeding continues, eport to
lacerations. physician right away.
• To stop the bleeding, these lacerations must be • 2. Massage the fundus every 15 minutes
repaired. during the first hour, every 30 minutes during
• If lacerations are discovered after the patient is the next hour, and then, every hour.
transferred to the recovery room or her private ASSESMENT OF THE FUNDUS
room, return woman immediately to the 3. Locate fundal height. Immediately after
delivery room for repair. placental delivery, it is located between the umbilicus
2.Classifications of perineal lacerations: and the symphisis. It gradually rises to the level of the
• First degree: Involves the fourchette, vaginal umbilicus afterwards. It should be located at midline
mucous membrane, perineal skin and firm. If the fundus deviates from the middle, check
• Second degree: Involving fourchette vaginal for fullness of the bladder which is usually the cause.
mucous membrane, perineal skin, muscles of 4. Assess the bladder when assessing the fundus.
perineal body Bladder distention displaces the uterus and prevents
• Third degree: Involves fourchette, vaginal proper uterine contaction. This can cause bleeding.
mucous membrane, perineal skin, muscles of ASSESSMENT OF LOCHIA FLOW
perineal body and anal sphincter • 1. Record the number of pads soaked with
• Fourth degree: Involves fourchette, vaginal lochia during recovery.
mucous membrane, perineal skin, muscles of • 2. Assess color, amount, smell, presence
perineal body, anal sphincter and mucous of clots.
membrane of rectum • 3. Observe for constant trickle of bright
• red lochia. If fundus is firm, this may be caused
by lacerations.
• 4. Observe lohia flow when the fundus is
massaged.
PROVIDING COMFORT AND PAIN RELIEF 
CARE OF PARTURIENT IN THE FOURTH STAGE • During the immediate postpartum period, the
woman may experience pain and discomfort fro
several causes which include cramping from
uterine contractions and perineal pain from
3. Midwifery care: episiotomy and delivery trauma.
• Perineal care: Clean the perineum with an • Relief can be provided by providing pain
antiseptic solution and apply a sterile sanitary medications and applying ice compress over the
pad on the perineum. An ice pack may be perineum.
applied to the perineum to reduce swelling TRANSFER TO RECOVERY OR PRIVATE ROOM
from episiotomy especially if a fourth degree • If the patient is transferred to the delivery or
tear has occurred. private room, ensure that emergency
• Lowe legs from the stirrups at the same time equipment is available for possible
and remove soiled drapes and linens. Change complications.
mother into clean gown. • 1. Suction and oxygen in case patient
• Provide extra blanket to keep patient warm. becomes eclamptic.
Chilling, called postpartum tremors, is common • 2. Pitocin® is available in the event of
at this period and is due to the circulatory hemorrhage.
changes that occurred after delivery. • 3. IV remains patent for possible use if
VITAL SIGNS complications develop.
• 1. Monitor vital sign every 15 minutes for • 4. Oxygen.
an hour then every 30 minutes for the next
hour. Then every hour until transferred to the ------ End-----
RR or private room.